it's in! (or, an ER moment)

First time I've successfully intubated a baby at the first try. It was a semi-emergency one too. The baby (an ex- 28 weeker weighing 1.5kg) was breathing at about 100/min and was rapidly tiring out, so needed to be put back on a ventilator. She was oxygenating ok though - until the suxamethonium went in. Her sats dropped to about 50% and her heart rate started to fall. The registrar took over bagging, and we turned the pressures gradually up. Though her chest was moving, the oxygen simply wasn't getting from her lungs to her bloodstream. "We'll just have to go for it," she said, handing me the laryngoscope. I'd let on that I was inexperienced, but had not mentioned I'd never actually been successful before (just in case they didn't let me do it). As it happened, the laryngoscope slid in easily over the (paralysed) baby's tongue. First the oesophagus, with the orogastric tube running down it, came into view. I moved the scope anteriorly, obtaining a perfect view of the vocal cords. I took the endotracheal (ET) tube (size 3.5) in my right hand (the laryngoscope is a left-handed intrument), asked the nurse to apply pressure to the cricoid, aimed for the chords, and there it was, in! Once the circuit was reconnected to the ET tube, the baby's chest moved beautifully. My first intubation. And nobody guessed it.

the other cases (notes for myself)

3 year-old filipino girl post PEG-insertion
known epilepsy usually on phenobarbitone, global developmental delay
called urgently to see due to prolonged fitting
airway ok, highflow O2 by facemask; IV in situ
no lorazepam on ward; given 5mg rectal diazepam
fitting continued; 0.1mg/kg lorazepam - fit terminated
o/e reduced air entry on left side
CXR - lung fields clear; marked scoliosis towards left. bloods - NAD
phenobarbitone level - within normal limits; reviewed by Neurology team
no further fits; started on 1/3 feeds, building up to full feeds over next 3 days
discharged with supply of diazepam


18 year-old bangladeshi girl
psedo-obstruction, peripheral nutrition-dependent, recurrent central line infections
new hickman line inserted 6 days ago. spiking temperatures
o/e alert, complaining of generalised aches, feeling cold (temperature 38.9)
no focal findings on examination; bounding pulse; imp: septic
bloods inc. cultures taken via hickman line.
already on fluconazole (candida on blood cultures from 10 days ago), amikacin, ciprofoxacin
, vancomycin (various resistant bacteria on previous blood cultures)
paeds gastro consultant phoned at home for advice on changing antibiotics;
?outcome unknown to me (will find out when i get back on day shifts)

15 year-old boy, known crohn's disease
had been admitted 3 weeks earlier due to weight loss and increased abdominal pain but was now getting ready for discharge, nearly up to full feeds.
called to see due to drop in blood pressure to 74/50; also tachycardic and low urine output
o/e drowsy, afebrile; no focal findings apart from tender abdomen (as usual)
2 large cannulas inserted; given 20ml/kg bolus of 0.9% saline
blood taken - raised CRP; neutrophilia; cultures taken despite lack of pyrexia
b.p still low after bolus; further bolus given
next day:
surgical review and contrast study showing stricture of ascending colon. planned for resection and stoma formation this week

5 year-old jewish girl post-tonsillectomy bleed
(2 admissions; once on monday night and once on saturday night)
tonsillectomy, adenoidectomy and bilateral grommets 6 days previously
attended Other hospital with earache; sent home on oral antibiotics. was put to bed only to awaken at 20:00 "covered in blood"
taken to Other hospital, but transferred to Our hospital as operation done by our ENT surgeons
had not been given any treatment at Other hospital!
o/e alert, but lethargic and very pale. blood-stained nightdress
imp: haemodynamically stable, no active bleeding. IV cannula inserted and bloods inc. group and save taken.
phoned ENT registrar for advice: IV co-amoxiclav, hydrogen peroxide mouthwash if active bleeding, IV fluids overnight, may eat in the morning if no further bleeding
discharged from hospital on wednesday, only to return on saturday
complained to mom of blood in throat at about 17:00; small vomits of blood
followed by a large vomit of blood about 18:15
dad said: "it was much worse than monday. the floor was covered and the whole couch was soaked. she couldn't walk straight. I lay her down with her legs propped up, and called an ambulance"
given 20ml/kg saline bolus on arrival to A&E; blood pressure came up nicely. by the time I saw her was alert and chatty. Hb 9.2; G&S already done.
advice as before; cef and met IV; for theatre if further bleeding overnight (this fortunately didn't happen)
*****************************

just a few of the patients I dealt with on nights. That's why I'm still tired. I can't really remember sunday (granted I slept for most of it), or yesterday (slept/sleepwalked through that too). Off sick today as feeling extremely run-down. Aches, shivers, and an unspeakable emotional tiredness from dealing with all the (justifiably) anxious parents. My only wish is that someone would ask me (with genuine concern) how I am for once.

refeeding

She was a little blonde waif with tired, pale blue eyes. Her England football jersey (with "Age 5" on the label) hung off her like a baggy nightdress. I've met anorexics before, but never one as young as *Jamie. She was nearly 9 and weighed 18 kilograms. The story was (and anorexics never tell the truth - it is part of the disorder) that she'd been at a talk on healthy eating at school, and had started cutting out crisps and cakes from her diet. One thing led to another, and eventually all she would eat was dry toast and a few sips of water. In the last few weeks she had become moody and had started sleeping in the afternoons. She'd been admitted into hospital to receive nasogastric feeds. My task as the night doctor was to do regular blood tests to check her phosphate, magnesium and calcium levels. These can become deranged when someone who has been starving for some time first receives nutrition - the refeeding syndrome.

It was a bit like taking blood from a very little old person. Her skin was dry and flaky, the veins knobbly and very mobile within her wrinkly arms. Her pulse was slow, at about 45/min and her blood pressure extremely low. The blood test results showed she was going into kidney failure, most likely from being so dehydrated. She hadn't had a wee for 36 hours. I dithered for ages about starting intravenous fluids - I didn't want her to be attached to too many lines for a prolonged period, but I also worried about giving her the fluid all at once (as a 'bolus') because of the risk of heart failure. I eventually opted for the latter, under close observation. It turned out to be the right decision.

Over the next few nights, her feeds were increased, and the frequency of blood tests decreased. She perked up dramatically, and on the fourth morning, sat up and smiled at me. She's got a long way to go, though. I'd thought that childhood anorexics had a better prognosis (in adults about 50% never recover and of these just under half die), but I've looked it up and it seems under-11s are significantly worse off.

12,000 junior doctors march through central london

If only they knew

*Musa is a 15 year old Bangladeshi boy, though the nurses on the children's surgical ward refer to him as "that man". He is of short and squat build, but has copious facial hair and bushy eyebrows shaved off in stripes at the ends. Maybe there is something about being advanced in puberty at an early age (though not pathologically so in his case) that brings out the worst in teenage behaviour. He was arrested by the police for suspected drug dealing, and was knocked to the ground in the scuffle, breaking a tooth and bruising the side of his face. He was drowsy and couldn't remember things afterwards, so was brought into hospital with a suspected head injury. A CT scan was normal, so it was the usual - referral to social work and neuropsychology - the surgeons weren't interested in his case.

Over the next day, he recovered and continued to be very polite to the nurses. Every time I saw him he would make up a new complaint calculated to keep him in hospital - first it was double vision, then it was a headache and nausea, then pain in his gums. I made the appropriate referrals, but was frankly getting a bit sick of the whole thing. I recalled Dr. M, one of the consultants, who would give any local teenager coming in with a suspected drugs offence, or even self-harm a good telling off in Bengali. Eventually Musa's old notes arrived, and I discovered he had been in hospital after similar incidents twice in the last 3 months.

I was annoyed because we had 5 very sick premature babies on the neonatal surgical unit that I had to look after as well. These babies had sepsis or necrotising enterocolitis, and were on ventilators. Then I had the fleeting idea of bringing Musa on to the Unit - perhaps if he saw the tiny, fragile babies he would realise how valuable his own life was, and how he was repeatedly and carelessly putting it in danger. But I couldn't of course. The parents (even the teenaged ones) would be horrified at the sight of a burly hoodlum in a hospital gown on the baby unit. Then again, perhaps it would be useful for them to meet Musa - 'this is what your baby could become, if you're not careful' the sight of him would say.